OCRC Use Only
OCRC
Number:
HUD Number:
Name of person or organization alleging harm:
Home Phone Number:
( )
Alternate Phone Number:
( )
Street Address
City
State
Zip
Email address:
Against whom is this charge being filed?
Phone Number
( )
Street Address
City
State
Zip
Check the applicable box or boxes which describe(s) whom the charge is being filed against:
Owner
Manager
Salesperson
Bank or other Lender
Broker
Other
If you named an individual above who appeared to be acting for a company in this case, write the name and address
of the company below.
Name:
Address:
Name and identify others (if any) you believe violated the law in this case:
3a. What is the address of the house or property? (street, city, county, state and zip code):
3b
.
Does the owner live at this address?
Yes
No
Unknown
4. What kind of house or property was involved?
Single-Family house
A house or building for 2, 3, or 4 families
A building for 5 families or more
Other, including vacant land held for residential use (explain):
5a. Is this house or property being sold?
Yes
No
Unknown
5b. Is the house or property being rented?
Yes
No
Unknown
Ohio Civil Rights Commission - Housing Discrimination Charge
6. Do you believe you were discriminated against because of your: (Check all that apply.)
Race
Color
Sex
Disability
National Origin
Ancestry
Religion
Military Status
Familial Status
Marital Status (mortgage credit only)
Retaliation
7. When did the act(s) of discrimination occur? (Include the most recent date if several dates are involved.)
8. What did the person you are complaining against do? (Check all that apply.)
Refuse to rent, sell, or deal with you
Falsely deny housing was available
Discriminate in the terms and conditions in the sale, rental, occupancy, or in services or facilities
Deny a reasonable accommodation
Deny a reasonable modification
Advertise in a discriminatory way
Threaten, intimidate, interfere, harass, or coerce you to keep you from the full benefit of the State or
Federal Fair Housing Law
Discriminate in financing
Engage in blockbusting
Engage in steering
Other
9. Please write a concise summary of what happened that you believe is an act of discrimination:
I declare under penalty of perjury that the foregoing is true and correct.
Signature: Date:
Sworn and subscribed before me on this day of of 20
Ohio Civil Rights Commission Representative or Notary